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F <br /> ,oPa �••co SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Ur x <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> • q., ;P• Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> <<F ORN ® - p� <br /> VECTOR CONTROL INSPECTION FORM <br /> DBA 1 INS <br /> PE1 DAT / <br /> Structure Operation / L y /6 <br /> ❑ ❑ 1. Well ConstructionPREMISE ADDRESS RE-INSPECTION DATE <br /> El El2. Cross-Connection4 `Y-� <br /> Structure Operation Manure managernept OWNEF310PERATOR /PONE <br /> E] 1:13. Spreading and Dis ing D C )ud�p`'f fs 7 C�'7 <br /> ❑ ❑ 4. Concrete Tanks INSPEATION TYPE PRO AM ELEMENT REC RD ID <br /> ❑ ❑ 5. Lagooning <br /> 10R-03W V62- <br /> 13 ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird DisposAl <br /> ❑ 1 7. Bu in ith 2"of Cover <br /> s �+ <br /> ❑ ❑ 8. Approv d Concrete Tank <br /> ❑ ❑ 9. Rem al from Premises r <br /> Structure Operation Vecto Control <br /> ❑ ❑ 10. omestic FI <br /> El El 11. annia FI <br /> ❑ ❑ 1 Larvae r <br /> ❑ ❑ X3. Pupae <br /> ❑ ❑ f 14. Adult <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population <br /> ❑ El 17. Heavy Population <br /> Structure Opyfti.n Feeding/Water <br /> ❑ ❑ 18. Water Troughs <br /> El1119. Cups or Bowls <br /> 20. Food Storage <br /> Structur Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ 22. Walls/Ceilings <br /> ❑ 23. Cleaning Fre gen <br /> Structure Operation <br /> ❑ ❑ Pl. Well Construction <br /> El El 2. Cross Connection -,4 <br /> Structure Operation< Fl r r <br /> perly Graded to Sewer <br /> ❑ ❑ 4. Drain <br /> ❑ ❑ 5. Smooth/Cleanable <br /> 6. Covin <br /> Frequency <br /> Structure Operation ` ` r <br /> ❑ ❑ Smooth/Cleanable <br /> ❑ ❑ —976leaning Frequency <br /> Structure Operati <br /> ❑ ❑ Condition �® <br /> 1 Sanitation <br /> Structure Operati <br /> ❑ ❑ <br /> Storage <br /> 3. Insect/Vermin <br /> Structure Operation nimal Disposal <br /> ❑ ❑ 14. Removal from Premises <br /> ❑ ❑ 15 <br /> Structure Op111 ', <br /> ewage D' al <br /> ❑ Septic System <br /> ❑ SStructure Opab1eS VBCCInatlOn RECEI BY INSP CTOR <br /> ertificate on remises n� <br /> VECTOR CONTROL INSPECTION FORM <br /> EHD 40-06 4/6/12 <br /> Page of <br />